The impact of educational interventions on antibiotic prescribing for acute upper respiratory tract infections in the ambulatory care setting: A quasi-experimental study

Evaluation of Multisite Programmatic Bundle to Reduce Unnecessary Antibiotic Prescribing for Respiratory Infections: A Retrospective Cohort Study

Background

The aim of this study was to evaluate the frequency of unnecessary antibiotic prescribing for Tier 3 upper respiratory infection (URI) syndromes across the Mayo Clinic Enterprise before and after a multifaceted antimicrobial stewardship intervention, and to determine ongoing factors associated with antibiotic prescribing and repeat respiratory healthcare contact in the postintervention period.

Methods

This was a quasi-experimental, pre/post, retrospective cohort study from 1 January 2019 through 31 December 2022, with 12-month washout during implementation from 1 July 2020 through 30 June 2021. All outpatient encounters, adult and pediatric, from primary care, urgent care, and emergency medicine specialties with a Tier 3 URI diagnosis were included. The intervention was a multifaceted outpatient antibiotic stewardship bundle. The primary outcome was the rate of antibiotic prescribing in Tier 3 encounters. Secondary outcomes included 14-day repeat healthcare contact for respiratory indications and factors associated with persistent unnecessary prescribing.

Results

A total of 165 658 Tier 3 encounters, 96 125 in the preintervention and 69 533 in the postintervention period, were included. Following intervention, the prescribing rate for Tier 3 encounters decreased from 21.7% to 11.2% (P < .001). Repeat 14-day respiratory healthcare contact in the no antibiotic group was lower postintervention (9.9.% vs 9.4%; P = .004). Multivariable models indicated that increasing patient age, Charlson comorbidity index, and primary diagnosis selected were the most important factors associated with persistent unnecessary antibiotic prescribing.

Conclusions

Outpatient antibiotic stewardship initiatives can reduce unnecessary antibiotic prescribing for Tier 3 URIs without increasing repeat respiratory healthcare contact. Advancing age and number of comorbidities remain risk factors for persistent unnecessary antibiotic prescribing.

Implementation of Antimicrobial Stewardship Interventions in Primary Care: Acute Bacterial Rhinosinusitis Treatment Strategies

BACKGROUND

The highest prescribing rates for antibiotics occur in primary care, therefore, ambulatory care pharmacist interventions could play a major role in preventing overuse and misuse of antibiotics. Delegated pharmacists in the SJC primary care setting guided 3 activities with a goal of positively impacting prescribing patterns: monthly webinars provided by Agency for Healthcare Research and Quality (AHRQ), quarterly reporting to physicians of antibiotic prescribing patterns, and development of a clinical decision-making support tool for antibiotic prescribing.

METHODS

Retrospective, observational data was collected to evaluate antibiotic prescribing patterns in patients diagnosed with acute sinusitis both before initiatives were implemented (July 1, 2019 through June 30, 2020) and after the initiatives were implemented (April 1, 2022 through June 30, 2022).

RESULTS

A total of 675 patients were diagnosed with acute bacterial sinusitis during the specified time frame. Of these, 138 patients were excluded. A total of 279 antibiotics were prescribed in the preintervention group out of 298 patient encounters (93.6%) and 225 antibiotics were prescribed in the post-intervention group out of 244 patient encounters (92.9%) (p = .26). Although the primary outcome was not statistically significant, a significant reduction in patients treated with fluoroquinolones was noted, with 59/298 (20%) of those being prescribed in the pre-intervention group and 20/244 (8%) in the post intervention group (P = .02).

CONCLUSIONS

While pharmacist-led antimicrobial stewardship interventions in primary care did not result in a decrease in the overall prescription of antibiotics for acute sinusitis, our study did reveal a notable reduction in the use of fluoroquinolones. This finding highlights a promising avenue for expanding the role of ambulatory care pharmacists.

Influenza colloidal gold method and blood routine tests combination for rapid diagnosis of influenza: a decision tree-based analysis

Rapid influenza diagnosis can facilitate targeted treatment and reduce antibiotic misuse. However, diagnosis efficacy remains unclear. This study examined the efficacy of a colloidal gold rapid test for rapid influenza diagnosis. Clinical characteristics of 520 patients with influenza-like illness presenting at a fever outpatient clinic during two influenza seasons (2017–2018; 2018–2019) were evaluated. The clinical manifestations and results of routine blood, colloidal gold, and nucleic acid tests were used to construct a decision tree with three layers, nine nodes, and five terminal nodes. The combined positive predictive value of a positive colloidal gold test result and monocyte level within 10.95–12.55% was 88.2%. The combined negative predictive value of a negative colloidal gold test result and white blood cell count > 9.075 × 10⁹/L was 84.9%. The decision-tree model showed the satisfactory accuracy of an early influenza diagnosis based on colloidal gold and routine blood test results.

Clinical impact of pharmacist-led antibiotic stewardship programs in outpatient settings in the United States: A scoping review

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

To provide an overview of the impact of pharmacist interventions on antibiotic prescribing and the resultant clinical outcomes in an outpatient antibiotic stewardship program (ASP) in the United States.

Methods

Reports on studies of pharmacist-led ASP interventions implemented in US outpatient settings published from January 2000 to November 2020 and indexed in PubMed or Google Scholar were included. Additionally, studies documented at the ClinicalTrials.gov website were evaluated. Study selection was based on predetermined inclusion criteria; only randomized controlled trials, observational studies, nonrandomized controlled trials, and case-control studies conducted in outpatient settings in the United States were included. The primary outcome was the observed differences in antibiotic prescribing or clinical benefits between pharmacist-led ASP interventions and usual care.

Results

Of the 196 studies retrieved for full-text review, a cumulative total of 15 studies were included for final evaluation. Upon analysis, we observed that there was no consistent methodology in the implementation of ASPs and, in most cases, the outcome of interest varied. Nonetheless, there was a trend toward improvement in antibiotic prescribing with pharmacist interventions in ASPs compared with that under usual care (P < 0.05). However, the results of these studies are not easily generalizable.

Conclusion

Our findings suggest a need for a consistent approach for the practical application of outpatient pharmacist-led ASPs. Managed care organizations could play a significant role in ensuring the successful implementation of pharmacist-led ASPs in outpatient settings.

Outcomes of an ambulatory care pharmacist-led antimicrobial stewardship program within a family medicine resident clinic

OBJECTIVE

To determine whether an ambulatory care pharmacist (AMCP)-led intervention improved outpatient antibiotic prescribing in a family medicine residency clinic (FMRC) for upper respiratory tract infections (URIs), urinary tract infections (UTIs), and skin and soft-tissue infections (SSTIs).

DESIGN

Retrospective, quasi-experimental study comparing guideline-concordant antibiotic prescribing before and after an antimicrobial stewardship program (ASP) intervention.

SETTING

Family medicine residency clinic affiliated with a community teaching hospital.

PARTICIPANTS

Adult and pediatric patients prescribed antibiotics for URI, UTI, or SSTI between November 1, 2017, and April 31, 2018 (pre-ASP group), or October 1, 2018, and March 31, 2019 (ASP group), were eligible for inclusion.

METHODS

The health-system ASP physician and pharmacist provided live education and pocket cards to FMRC staff with local guidelines as a quick reference. Audit with feedback was delivered every other week by the clinic's AMCP. Guideline-concordance was determined based on the institution's outpatient ASP guidelines.

RESULTS

Overall, 525 antibiotic prescriptions were audited (pre-ASP n = 90 and ASP n = 435). Total guideline-concordant antibiotic prescribing at baseline was 38.9% (URI, 53.3%; SSTI, 16.7%; UTI, 46.7%) and improved across all 3 infection types to 57.9% (URI, 61.2%; SSTI, 57.6%; UTI, 53.5%; P = .001). Significant improvements were seen in guideline-concordant antibiotic selection (68.9% vs 80.2%; P = .018), dose (76.7% vs 86.2%; P = .023), and duration of therapy (73.3% vs 86.2%; P = .02).

CONCLUSIONS

An AMCP-led outpatient ASP intervention significantly improved guideline-concordant antibiotic prescribing for common infections within a FMRC.